Therapeutic relationships are the cornerstone of nursing practice with people who are experiencing threats to their physical and mental health. An effective therapeutic alliance is one of the key factors that help clients to develop alternative modes of coping with intolerable affects when habitual self-harm has become common (Walsh, 2007).
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The concept of the therapeutic nurse-patient relationship evolved from the work of Hildegard Peplau in the 1950’s (Forchuk and Reynolds, 1998). Peplau (1988) held the view that whilst relationships may contribute to dysfunctional behaviour, people can also heal within relationships. Peplau’s Interpersonal theory of nursing focuses on the evolving therapeutic relationship between the nurse and client. Peplau (1998) identifies overlapping phases. Firstly the orientation phase, in which parameters of the relationship are established and initial trust develops. Secondly, the working phase, which includes problem identification and exploitation (making full use of the services of the nurse) and finally the resolution phase, this engages the termination of the relationship (Forchuk, 1995). The current health care environment, including shortage of nurses, economic constraints and advances in pharmacology, has led some to question the relevance of Peplau’s model in current nursing practice (Ziegler, 2005). For example, Hagerty and Patusky (2003) discuss that the long-term relationship development is no longer useful in most health care settings. Conversely, Gastman’s (1998) argues that the fundamental concepts found in the interpersonal relations theory are still useful.
Development of a therapeutic relationship has been identified as being particularly complicated where self-harm is involved. It is not unusual that self-injurers encounter professionals that respond ineptly to their behaviour. Many authors (e.g., Simeon and Hollander, 2001; Walsh, 2006) have discussed negative reactions, such as shock, disgust, fear and anxiety, that self-injurers experience when they first encounter professionals such as nurses. This may lead to individuals who self-harm being ‘sceptical’ of the continuity and longevity of the therapeutic relationship (Walsh and Rosen, 1988). Although these preconceptions exist both for the nurse and client, a therapeutic relationship is vital. The guidelines provided by the National Institute for Clinical Excellence (NICE, 2004) for the management of self-harm, suggest that a therapeutic relationship is often more important than the treatment. Furthermore although a positive therapeutic relationship is not the solution to self-injury, it provides a context in which problem solving and behaviour change can take place (Nafisi and Stanley, 2007). Therefore it is essential that the skills used in the orientation phase to develop trust are continued and expanded upon throughout the relationship. Shiner (2008) identifies it is important to maintain a non-judgemental, empathetic, open-minded and respectful attitude with the focus kept on the person and not on their self-harm behaviour. These underlying principles are congruent with the much earlier work of Peplau (1952) and Rogers (1957). The use of empathy has been identified as a key component when working with an individual who self-harms, the ability to communicate an understanding of what they are going through may alter the individuals’ perception of adults and their previous experiences (Davies & Huws-Thomas, 2007).
For problem solving and behaviour changes to take place collaborative care is important to identify the needs individual to the patient. Collaborative working ensures that both the nurse and patient influence the decision making process (Ellis, 2009). Hence, Nurses should deal with the ‘persons’ description of their own immediate needs, this is something The Tidal Model recognises. The Tidal Model advocates an essentially curious and broad-minded stance towards people’s problems. The model incorporates elements of alliance, evocation of resourcefulness (recognising the individual already has acquired abilities and skills) and achievable therapeutic goals all of which are essential to collaborative care (Barker, 2005). The philosophical underpinning of this model draws upon the earlier work of Peplau (1952) which further supports the relevance of Peplau’s model in today’s practice. A recent study by Cook et al (2005) illustrates the interpersonal transactions displayed when The Tidal Model is implemented, as being positive for recovery. This emphasizes the use of this model when mental health nursing is fundamentally aiding someone on their journey to recovery.
The working phase of Peplau’s model is initially concerned with identification. During this phase of the therapeutic relationship the nurse in partnership with the client carries out an assessment to identify problems that require working on within the relationship (Peplau, 1988). Unfortunately, relatively little has been written on the formal assessment of self-harm. This absence is regrettable because any effective treatment of self-injury must begin with a thorough and accurate assessment to identify needs and problems (ref). However evidence has shown the benefits of providing well co-ordinated care and treatment to those suffering with mental ill-health (Welsh Assembly Government (WAG), 2010). Consequently because mental ill-health is common in individuals who self harm surely well co-ordinated care should be of benefit. The WAG (2010) identify that clients often require help with aspects of their lives in addition to care and treatment, such as education and their physical health. This places demands on services that one discipline cannot meet alone, and it is therefore a requirement to have an integrated system of effective assessment, planning delivery and review, so that collaborative care can be provided to benefit the client. The framework for this integrated system is the Care Programme Approach (CPA).
CPA was initially introduced in England in 1991 to provide a framework for effective mental health care. This was mirrored in Wales by the introduction of ‘Guidance on Care Planning’ process and documentation in 1998. Fundamentally, the CPA is a problem solving process designed to facilitate effective and efficient clinical management of a client which involves five stages: Assessment, design of an individualised care-programme to meet indentified needs, appointment of a key worker, regular reviews to monitor the quality of the care being provided and to evaluate the effect of the care and finally discontinuation of the care programme when it is deemed appropriate (Kingdom, 1994). In essence the CPA introduced no major changes in to psychiatric care and should have merely formalised good care. However many have found this not to be the case and the CPA has been subject to major criticism with it being unevenly implemented (Social Services Inspectorate, 1999) and clients have reported it to be ‘invisible’ and ineffectual (Webb et al, 2000; Rose, 2001). These findings may suggest that the use of the CPA is ineffective however the framework is still widely used today and from personal experience it does help to co-ordinate the care and if it’s purpose is explained adequately this helps to eradicate the negative perceptions of clients by enhancing their understanding. (how might the mental health measure impact on CPA?)
Assessment is the first stage of the CPA framework which needs to be personalised to suit the individual who is self-harming. A Psychosocial assessment following self-harm, as outlined in the NICE (2004) guidance, is a necessary starting point for preventive interventions (Hawton et al, 19998). To carry out a psychosocial assessment means to recognise the importance of, and interrelationships between, psychological and social domains of the client’s life. A recent study carried out by Bergen et al (2010) found a psychosocial assessment following self-harm was associated with a 53% decreased risk of a repeat self-harm episode in individuals without a mental health diagnose and 26% decreased risk in those with a mental health diagnoses. These findings, although lower if an individual has a mental health diagnosis, support the importance of a psychosocial assessment. More importantly these findings identify that such assessment can reduce repetition of self-harm. However, the findings may be limited because some diagnostic factors, including previous or current mental health diagnoses, were not available. Nonetheless, the large sample may override this deficit and therefore the findings could be generalised to pose as a good representation of the wider population. Furthermore, previous studies (e.g. Hickey et al., 2001; Kapur et al., 2002) have also highlighted that psychosocial assessment appears to reduce repetition by 50%, which offers reliability to the more recent findings.
Although a psychosocial assessment has been proven to reduce the risk of repetition there are a high proportion of individuals who will continue to self-harm after an assessment (Hawton et al, 2003), with one percent of individuals going on to commit suicide in the 12 months following the assessment (Hawton and Fagg, 1998). Therefore, before formulating a care plan, a risk assessment to identify risk-factors for future self-harm is a nursing priority. Risk assessment is integral to the management of individuals with a mental disorder and a vital part of the CPA framework (Phull, 2012). Risk has been defined as the likelihood of an event happening with potentially harmful or beneficial outcomes for the self and or others (Morgan, 2000). In mental health nursing it is not uncommon for the ‘event’ to be referred to as behaviours resulting in suicide, self-harm, neglect and violence. Because of the high risk of death associated with these behaviours it may explain why until recently there has been little or no consideration of the positive potentials of risk taking. The Best Practice in Managing Risk (DoH, 2007) identifies that positive risk taking aids recovery and by avoiding all possible risks it may be counterproductive creating more problems for the patient in the long term. Therefore positive risk management is essential and can be achieved by using a collaborative approach.
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The ability to assess risk effectively is an essential skill for mental health staff working with patients who harm themselves. The assessment should include identification of the main clinical and demographic features known to be associated with the risk of further self-harm and or suicide, and identification of the key psychological characteristics associated with risk, in particular depression, hopelessness and continuing suicidal intent (NICE, 2004). The means of collecting this information includes using past clinical notes, information gathered from the psychosocial assessment, actuarial assessment tools and clinical judgement, as well as working closely with the patient to anticipate their future behaviour (Doyle 1999, Morgan 2007).
In clinical practice there are a number of actuarial risk assessment tools which invariably provide practitioners with prompts to ensure that all aspects of the risk assessment are considered. Self-harm has been identified as a main predictor of suicide therefore risk assessment tools to help identify any suicidal ideation would aid the nurse. The Becks hopelessness scale (BHS; Beck et al, 1979) has been recognised as a useful tool to predict repetition of self-harm and suicide (DoH, 2007). If repetition of self-harm is identified as being likely, the Functional Assessment of Self-Mutilation (FASM; Lloyd et al, 1997) assessment tool may be used to determine what type of self-harming behaviour may prevail. The incorporation of specific risk assessment tools has been described by some as creating the ‘ideal’ assessment (Brown et al, 2004). However, the usefulness of such tools has been questioned because such tools tend to focus on common behaviours and more often than not they have primarily been developed for research purposes (Walsh, 2007). Because of these limitations the use of risk assessment tools alone would not ensure a valid risk assessment and should be used to aid clinical judgement only.
Once a comprehensive psychosocial risk assessment has been completed, collaboratively the nurse and client identify together the needs that need to be addressed to formulate a care and treatment plan. Although a care plan is a fundamental part of the CPA framework it is now a legal requirement under the Mental Health (Wales) Measure 2010. (very good) This new standardised care plan consists of eight domains, recognising that there are a number of aspects that collectively contribute to an individual’s mental well being. These include accommodation, education and training, finance and money and medical and other forms of treatment, including psychological interventions. Because this is a standardised care plan it is arguable that some of the domains may not apply to adolescents. The Welsh Government have addressed this in their code of practice and have suggested that for adolescents, best practice would be for outcomes across the domains to also consider attainment of achievable physical, psychological and social development goals and interventions (Welsh Government, 2012).
For the purpose of the next chapter the ‘medical and other forms of treatment, including psychological interventions’ will be the domain primarily focused on.
To summarise, a therapeutic relationship based on
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